Healthcare systems are increasingly targeted by malicious actors, and Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are particularly vulnerable. Since they are required to comply with the Health Information Portability and Accountability Act of 1996 (HIPAA), these health systems must safeguard sensitive patient information. However, they often face significant challenges, including limited budgets and insufficient workforce resources to invest in cutting-edge technology to maintain robust security measures.
HIPAA mandates that these organizations conduct security risk analyses to gauge threats and vulnerabilities to protected health information (PHI). Historically, these assessments have been basic, failing to evolve alongside the rapidly changing threat landscape. In addition, security risk analyses are not public-facing certifications, meaning they cannot be leveraged to satisfy cybersecurity insurance underwriters or other external stakeholders.
The Health Information Trust Alliance (HITRUST) was established to address the unique challenges facing rural community healthcare providers and offer a resource tailored to help meet the needs of these organizations. To this end, HITRUST developed the common security framework (CSF), a certifiable program that gives healthcare organizations and their providers a consistent methodology to demonstrate security and compliance. HITRUST CSF consists of several validated assessment types that organizations can utilize to help achieve compliance. Over time, the HITRUST CSF has become an industry-recognized standard for helping ensure HIPAA compliance. HITRUST CSF consists of several validated assessment types that organizations can utilize to help achieve compliance.
The HITRUST e1 Assessment provides an accessible yet in-depth approach for RHCs operating under tight financial constraints. This foundational assessment encompasses 44 essential security controls and can be tailored to include HIPAA’s Security, Breach Notification, and Privacy Rules, resulting in a more holistic evaluation. Below is an outline of the additional requirements added for each HIPAA Rule:
- e1 Validated Assessment plus HIPAA Security = 108 requirements
- e1 Validated Assessment plus HIPAA Security and Breach Notification = 118 requirements
- e1 Validated Assessment plus HIPAA Security, Breach Notification, and Privacy = 220 requirements
HITRUST Validated Assessments consist of a self-assessment conducted by the entity being evaluated, followed by an independent validation performed by a HITRUST-authorized external assessor. Upon completion of this validation, the assessment is submitted to HITRUST for a final review by a HITRUST Quality Assurance (QA) analyst.
HITRUST certifications, such as the HITRUST e1 Validated Assessment, can be categorized as allowable costs for RHCs and FQHCs under compliance-related budgetary allocations. HITRUST CSF implementation aligns with organizations’ obligations to safeguard patient data and demonstrate security and compliance, which helps them meet regulatory requirements (such as HIPAA mandates).
The cost of a HITRUST Assessment can be justified as part of necessary operational expenses aimed at mitigating risks, ensuring data integrity, and addressing vulnerabilities. By incorporating HITRUST Assessments into their budgets, RHCs and FQHCs not only work toward meeting compliance standards but also strengthen their cybersecurity posture to help protect against evolving threats. Moreover, having a HITRUST certification may enhance their eligibility for cybersecurity insurance and improve stakeholder confidence, helping to add measurable value to their operations.
Preparing for certification and performing a validated assessment can be a substantial undertaking, so it is important to choose a firm with services extending beyond simple compliance. At Forvis Mazars, our experienced professionals can work with you to develop strategies to help your compliance reporting needs and provide valuable insights along the way.
For more information on these services, please reach out to a professional at Forvis Mazars.